End of Life Care Education MODULE 1 Module 4 Communication in End of Life Care

Importance - Guidelines Honest, accurate and early disclosure of prognosis Consensus among family and between family and physicians Discussion and communication of modalities of end- if-life care with family Shared decision-making Ensure consistency among family members Effective and compassionate support throughout, including bereavement care

Ethical principles Autonomy Beneficence Non-malfeasance Social justice

Goals of communication during end-of-life discussions Establishing consensus about the disease process among care-givers Providing accurate and appropriate information about the disease process to the family Eliciting and resolving the concerns prompted by end-of-life decisions (EOLD)

Communication skills at EOLD Ability to distinguish between cognitive and emotional components in the concerns expressed by patient and family Use of empathy Ability to understand and clarify doubts ”Active listening”

S-P-I-K-E-S approach in patient and family centered communication Setting – time, space, privacy Perceptions – of the family/patient about the illness and progress Invitation – family/patient expresses a wish to discuss about the illness and management options Knowledge – about the illness and prognosis informed to the family in a clear understandable language Emotional support and Empathy – Identifying the emotions in the family and responding appropriately to it Strategy and summary – summarizing the current situation, further plans for comfort care and accurate documentation

Patient and family centered communication - components Empathy Collaboration Clarification Avoid being judgmental Perception of patient’s wishes Recapitulation

The VALUE mnemonic Value statements by family members Acknowledge family members’ emotions Listen to family members Understand who the patient is as a person and how decisions are made in the family Elicit questions from family members

Non-verbal communication-‘SOLER’ Face the patient Squarely at eye level and indicate your involvement and interest Adopt an Open body posture Lean towards the patient and family Use Eye contact to show that you are listening attentively to the patient Maintain a Relaxed body posture

Different communication styles of physician Inexperienced messenger Emotionally burdened Rough and ready expert Well-intentioned but tactless expert Distanced expert Empathic professional

Conflicts during EOLD Gap between ‘what is’ and ‘what should be’ Failure to achieve consensus in goals of care and related treatments at EOL despite allowing time and repeated discussions between involved parties Various factors

Some barriers to good communication and contributors of conflicts in EOLC Patient or family Psychosocial distress/strong emotion Language, cultural barriers Lack of understanding of context Physician Communication skills Depth of understanding of patient’s condition Lack of consensus among medical team Grounding of medical ethics Environmental Type of hospital Developed/developing country Society’s expectations from medicine

CONFLICT RESOLUTION TRUST HOPE EMPATHY

LATER After death care Bereavement support

CONCLUSION Importance of communication skills in EOLD Approaches Styles Barriers Conflict resolution

THANK YOU This education program is a joint initiative of Indian Society of Critical Care Medicine and Indian Association of Palliative Care. 2014 © All rights reserved